| Dental Cleaning - Adult | $99 | N/A | $99 |
| Dental Cleaning - Child | $79 | N/A | $79 |
| Dental Exam - Comprehensive | $84 | N/A | $84 |
| Dental Exam - Periodic, Established Patient | $48 | N/A | $48 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $302 | N/A | $302 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $239 | N/A | $239 |
| Dental Filling - White (Resin): One Surface, Posterior | $167 | N/A | $167 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $182 | N/A | $182 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $232 | N/A | $232 |
| Flouride - Topical Varnish Application | $50 | N/A | $50 |
| Maintenance Therapy - Periodontal | $145 | N/A | $145 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $255 | N/A | $255 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $94 | N/A | $94 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $58 | N/A | $58 |
| Tooth Extraction - Elevation and/or Forceps Removal | $173 | N/A | $173 |
| X-Ray - Complete Intraoral Series | $141 | N/A | $141 |
| X-Ray - Four Images, Bitewings | $66 | N/A | $66 |
| X-Ray - Intraoral, Periapical Radiographic Image | $35 | N/A | $35 |
| X-Ray - Two Images, Bitewings | $48 | N/A | $48 |
| X-Ray - Whole Mouth from Outside Mouth | $127 | N/A | $127 |
